Overview and CQC Inspections

OverallRequires improvement

Our inspector's description of this service

Last updated 6 May 2017
We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

This comprehensive inspection took place on 24 August 2016. Three inspectors and an expert by experience completed this inspection. An expert by experience is a person who has experience of this type of service. At both the last comprehensive inspection which took place on 3 February 2015, and the last focussed inspection took place 6 September 2015, we assessed there were some areas of practice, including staffing levels, that needed to improve. At this inspection we checked whether these improvements had been made.

Before the inspection we reviewed the information we held about the service and the statutory notifications they had sent us. A notification is a form that the provider completes to inform us about incidents that have occurred which they are required to tell us about by law. On this occasion we did not ask the provider to complete a Provider Information Return (PIR). This is a form that asks the provider to give some key information about the service, what the service does well and improvements they plan to make. This is because we completed this inspection earlier than originally planned.

During our inspection we observed the care being delivered at meal times in four areas of the service and used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us. We observed staff administering medicines and some of the activities as well as the care provided to people throughout the day. We spoke with eleven people who used the service, the registered manager, the deputy manager, two team leaders one of whom was a registered nurse, eight care staff, the activities organiser, the four visiting relatives and three visiting health care professionals. We looked at ten people’s care plans, three people’s medication records, the staff duty rota, five staff recruitment files, meeting minutes, the complaints log, accident and incident records, an overview of training that staff had completed and an overview of the supervisions and annual appraisals that had taken place. We also looked at some of the providers’ health and safety records and quality assurance audits.

Inspection ratings

We rate most services according to how safe, effective, caring, responsive and well-led they are, using four levels:

Outstanding – the service is performing exceptionally well.

Good – the service is performing well and meeting our expectations.

Requires improvement – the service isn't performing as well as it should and we have told the service how it must improve.

Inadequate – the service is performing badly and we've taken enforcement action against the provider of the service.

No rating/under appeal/rating suspended – there are some services which we can’t rate, while some might be under appeal from the provider. Suspended ratings are being reviewed by us and will be published soon.

Ticks and crosses

We don't rate every type of service. For services we haven't rated we use ticks and crosses to show whether we've asked them to take further action or taken enforcement action against them.

There's no need for the service to take further action. If this service has not had a CQC inspection since it registered with us, our judgement may be based on our assessment of declarations and evidence supplied by the service.

The service must make improvements.

At least one standard in this area was not being met when we inspected the service and we have taken enforcement action.